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					                                                        Asian Pacific Journal of Tropical Biomedicine (2011)39-42                                    39


                                                         Contents lists available at ScienceDirect


                                        Asian Pacific Journal of Tropical Biomedicine
                                                  journal homepage:www.elsevier.com/locate/apjtb



Document heading                  doi:10.1016/S2221-1691(11)60065-8

Antibiotic sensitivity pattern of bacterial pathogens in the intensive care unit of
Fatmawati Hospital, Indonesia
Maksum Radji1*, Siti Fauziah1, Nurgani Aribinuko2
1
  Laboratory of Microbiology and Biotechnology, Department of Pharmacy, Faculty of Mathematics and Science, University of Indonesia, Depok,
16424, Indonesia
2
 Department of Intensive Care Unit, Fatmawati Hospital, Jakarta, Indonesia

ARTICLE INFO                                          ABSTRACT

Article history:                                     Objective: To evaluate the sensitivity pattern of bacterial pathogens in the intensive care unit
Received 2 September 2010                            (ICU) of a tertiary care of Fatmawati Hospital Jakarta Indonesia. Methods: A cross sectional
Received in revised form 27 September 2010           retrospective study of bacterial pathogen was carried out on a total of 722 patients that were
Accepted 15 Octorber 2010                            admitted to the ICU of Fatmawati Hospital Jakarta Indonesia during January 2009 to March 2010.
Available online 1 February 2011                     All bacteria were identified by standard microbiologic methods, and their antibiotic susceptibility
                                                     testing was performed using disk diffusion method. Results: Specimens were collected from
Keywords:                                            385 patients who were given antimicrobial treatment, of which 249 (64.68%) were cultured
Antibiotic susceptibility                            positive and 136 (35.32%) were negative. The most predominant isolate was Pseudomonas
Intensive care unit                                  aeruginosa (P. aeruginosa) (26.5%) followed by Klebsiella pneumoniae (K. pneumoniae) (15.3%)
Bacterial resistance                                 and Staphylococcus epidermidis (14.9%). P. aeruginosa isolates showed high rate of resistance
Bacterial pathogen                                   to cephalexin (95.3%), cefotaxime (64.1%), and ceftriaxone (60.9%). Amikacin was the most
Sensitivity pattern                                  effective (84.4%) antibiotic against P. aeruginosa followed by imipenem (81.2%), and meropenem
Antimicrobial                                        (75.0%). K. pneumoniae showed resistance to cephalexin (86.5%), ceftriaxone (75.7%), ceftazidime
Resistance                                           (73.0%), cefpirome (73.0%) and cefotaxime (67.9%), respectively. Conclusions: Most bacteria
Pseudomonas aeruginosa                               isolated from ICU of Fatmawati Hospital Jakarta Indonesia were resistant to the third generation
Klebsiella pneumoniae                                of cephalosporins, and quinolone antibiotics. Regular surveillance of antibiotic susceptibility
Isolate                                              patterns is very important for setting orders to guide the clinician in choosing empirical or
Specimen                                             directed therapy of infected patients.




                                                                                       rates of infection, especially infections due to resistant
1. Introduction                                                                        Staphylococci, Acinetobacter, Pseudomonas species,
                                                                                       and Candida species. Moreover, the ICU mortality of
 Antibiotic resistance is a major world-wide problem in the                            infected patients was more than twice that of non-infected
intensive care unit (ICU), including in Indonesia. It has been                         patients[4]. Most ICU patients that acquired infections are
realized that the spread of drug resistant organisms in the                            associated with the use of invasive devices such as catheters
ICU is related to the widespread use of antibiotics. The rate                          and mechanical ventilators[5].
of antimicrobial resistance in the ICU is several folds higher                            Globally, patients in the ICU have encountered an
than in the general hospital setting. Many surveillance                                increasing emergence and spread of antibiotic-resistant
efforts have drawn attention to this phenomenon[1-4].                                  pathogens. The worldwide incidence rate is 23.7 infections
   ICU is one of potential sources of nosocomial infections                            per 1 000 patient days. Rates of nosocomial infections
even in countries where extensive infection control                                    range from 5 % to 30 % among ICU patients. Although
measures are routinely implemented. The international                                  ICUs generally comprise < 5% of all hospital beds, they
study of infection in ICU which was conducted in 2007, and                             account for 20% to 25% of all nosocomial infections. The
involved with 1 265 ICUs from 75 countries, demonstrated                               increased risk of infection is associated with the severity of
that patients who had longer ICU stays had higher                                      the patient’s illness, length of exposure to invasive devices
                                                                                       and procedures, increased patient contact with healthcare
  *Corresponding author: Dr. Maksum Radji, M Biomed, Laboratory of Microbiology        personnel and length of stay in the ICU[6].
and Biotechnology, Department of Pharmacy, Faculty of Mathematics and Sciences            In Indonesia, there have been few studies of antibiotic
University of Indonesia, Depok, 16424, Indonesia.
  Tel: 62-21-78849002                                                                  use, especially in ICU setting. Therefore, the objective of
  Fax: 62-21-7863433                                                                   this study was to determine the antibiotic sensitivity pattern
  E-mail: maksum@farmasi.ui.ac.id
40                                        Maksum Radji et al./Asian Pacific Journal of Tropical Biomedicine (2011)39-42


of bacteria isolated from patients in the ICU of Fatmawati                         Enterobacter aerogenes (E. aerogenes) (13.3%), Klebsiella
Hospital, Jakarta, Indonesia.                                                      ozaenae (K. ozaenae) (8.4%), Escherichia coli (E. coli) (5.2%),
                                                                                   Serratia liquifaciens (S. liquifaciens), respectively, as shown
                                                                                   in Table 1. In this study almost bacteria isolated from ICU
2. Materials and methods                                                           of Fatmawati Hospital Jakarta Indonesia were resistant to
                                                                                   cephalexin (75%-95%) as shown in Table 2.
   A cross-sectional study was carried out based on reports
of bacteria isolates from the ICU of Fatmawati Hospital,                           Table 1
from January 2009 to March 2010. The Fatmawati Hospital                            The frequency of microorganisms isolated from patients admitted in
                                                                                   ICU of Fatmawati Hospital [n (%)].
is a tertiary care and teaching hospital with 740 beds, which
was located in Jakarta, Indonesia. During this period, 722                         No        Microorganism                            Frequency
patients were admitted to the ICU, and 385 of them received                          1       P. aeruginosa                             66 (26.5)
antimicrobial treatment. All samples that were collected                             2       K. pneumoniae                             38 (15.3)
aseptically from the 385 patients were plated right after the                        3       S. epidermidis                            37 (14.9)
collection. Identification of all causative microorganisms                           4       E. aerogenes                              32 (13.3)
was performed by standard microbiologic methods.                                     5       K. ozaenae                                21 (8.4)
Susceptibility testing was performed using disk diffusion                            6       E. coli                                   13 (5.2)
method. The results were interpreted according to the                               7        S. liquifaciens                            10 (4.0)
guidelines of the Clinical and Laboratory Standards Institute                       8        Staphylococcus aureus                       8 (3.2)
(CLSI)[7].                                                                          9        Klebsiella spp.                             5 (2.0)
                                                                                   10        Serratia marcessens                         4 (1.6)
                                                                                   11        Pseudomonas fluorescens                     3 (1.2)
3. Results                                                                         12        Enterobacter cloacae                        2 (0.8)
                                                                                   13        Enterobacter spp.                           2 (0.8)
  During January 2009 to March 2010, 249 (64.68%) of the                           14        Streptococcus group A                       1 (0.4)
385 specimens, were culture positive and 136 ( 35.32%)                             15        Pseudomonas putida                          1 (0.4)
specimens showed no growth. The most common locations                              16        Acinetobacter baumannii                     1 (0.4)
for infection were respiratory tract (78.7%), urinary tract                        17        Klebsiella terrigena                        1 (0.4)
(7.6%), surgical site (7.5%), blood (3.8%), and peritoneal                         18        Proteous mirabilis                          1 (0.4)
fluid (2.4%). Pseudomonas aeruginosa (P. aeruginosa) was                           19        Raoutella ornithinolytica                   1 (0.4)
the most frequently isolated bacteria (26.5%), followed                            20        Burkholderia cepacia                        1 (0.4)
by Klebsiella pneumoniae (K. pneumoniae) ( 15.3 %),                                          Total                                    249 (100.0)
Staphylococcus epidermidis (S. epidermidis) ( 14.9 %),
Table 2
Antibiotic resistance pattern of predominant microorganisms isolated from patients admitted in ICU of Fatmawati Hospital (%).
Antibiotic                P. aeruginosa      K. pneumoniae S. epidermidis                 E. aerogenes         K. ozaenae   E. coli      S. liquifaciens
                          (n=66)             (n=38)        (n=37)                         (n=32)               (n=21)       (n=13)       (n=10)
Cephalexin                95.3               86.5                  75.0                   83.9                  95.2        76.9         90.0
Ceftazidime               42.2               73.0                  72.2                   58.1                  85.7        38.5         30.0
Ceftriaxone               60.9               75.7                  64.9                   61.3                  85.7        46.2         70.0
Cefotaxime                64.1               67.9                  67.9                   67.7                 100.0        46.2         50.0
Cefepime                  35.9               56.8                  54.1                   38.7                  61.9        38.5         30.0
Cefpirome                 59.4               73.0                  56.8                   67.7                  81.9        38.5         50.0
Imipenem                  18.8                5.4                  18.9                    3.2                   9.5         0.0         20.0
Meropenem                 25.0                5.4                  32.4                    3.2                   9.5         7.7         10.0
Amikasin                  15.6               10.8                   0.0                    3.2                   9.5        15.4         20.0
Gentamicin                39.1               59.5                   0.0                   61.3                  76.2        38.5         40.0
Ciprofloxacin             56.3               64.9                  63.9                   51.6                  85.7        46.2         60.0
Ofloxacin                 53.1               62.2                  58.3                   48.4                  76.2        46.2         70.0
Moxifloxacin              50.0               62.2                  38.9                   45.2                  76.2        30.8         60.0
Levofloxacin              42.2               62.2                  50.0                   41.9                   6.2        53.8         60.0
Fosfomycin                28.1                2.7                  29.7                   12.9                  23.8         7.7          0.0


                                                                                   Indonesia [8]. Another study showed the most frequent
4. Discussion                                                                      bacteria isolated in Dr. Kariadi Hospital, Semarang
                                                                                   Indonesia were P. aeruginosa (50.9%), E. aerogenes (37.5%)
  This result revealed that P. aeruginosa, Klebsiella spp.,                        and E. coli (8.7%). P. aeruginosa demonstrated multidrug
and E. coli were still predominant isolates as previously                          resistance to several antibiotics[9].
investigated in ICU of Fatmawati Hospital Jakarta,                                   A very high rate of resistance (>72%) was observed among
                                         Maksum Radji et al./Asian Pacific Journal of Tropical Biomedicine (2011)39-42
                                                                                                                                                   41

S. epidermidis and Klebsiella spp isolates to ceftazidime,                        from ICU samples were P. aeruginosa, Klebsiella spp. and
whereas E. coli, S. epidermidis, E. aerogenes, P. aeruginosa,                     Staphylococcus aureus.
Klebsiella spp. and Serratia spp., resistant to ceftriaxone.                         In Canada, the Canadian National Intensive Care
P. aeruginosa isolates showed high rate of resistance to                          Unit study conducted during 2005-2006, showed that P.
cephalexin (95.3%), cefotaxime (64.1%), and ceftriaxone                           aeruginosa, Staphylococcus aureus, Haemophilus influenzae,
(60.9%). Amikacin was the most effective (84.4%) antibiotic                       Enterococcus spp., Staphylococcus pneumoniae, and K.
against P. aeruginosa followed by imipenem (81.2%), and                           pneumoniae are the most common isolates recovered
meropenem (75.0%).                                                                from clinical specimens in Canadian ICU s. Moreover,
    We found that K. pneumoniae was also multidrug                                P. aeruginosa is the most frequent multi drug-resistant
resistant bacteria to the third generation cephalosporins,                        phenotype, which is resistance to three or more of the
and quinolone antibiotics. K. pneumoniae showed high rate                         antibiotics including cefepime, piperacillin-tazobactam,
of resistance to cephalexin (86.5%), ceftriaxone (75.7%),                         meropenem, amikacin or gentamicin, and ciprofloxacin[30].
ceftazidime (73.0%), cefpirome (73.0%) and cefotaxime                                In Indonesia, beside P. aeruginosa, another multi
(67.9%). Similar observations to our study demonstrated                           drug resistant E. coli was also found as pathogen of
that 96%-100% K. pneumoniae and P. aeruginosa isolated                            nosocomial infection[31], furthermore these E. coli isolates
from ICU patients were resistant to ceftazidime[10,11]. K.                        were high rates of resistance to ampicillin, ciprofloxacin,
pneumoniae isolates were also resistant to ciprofloxacin                          chloramphenicol, and trimethoprim-sulphamethoxazole[32].
( 64.9 %), ofloxacin ( 62.2 %), moxifloxacin ( 62.2 %), and                          The prescribing of antibiotics in the ICU is usually
levofloxacin (62.2%). This finding is related most probably                       empiric. Therefore, the ongoing surveillance of antibiotic
due to the extensive usage of third generation cephalosporins                     susceptibility patterns of predominant bacteria is a
and quinolone antibiotics at the ICU of Fatmawati Hospital.                       fundamental effort to monitor changes in susceptibility
Another interesting result of this study is fosfomycin showed                     patterns and to guide the clinician in choosing empirical
good sensitivity against all bacteria isolated from ICU                           or directed therapy appropriately, especially in ICU setting.
admitted patients, most probably because this antibiotic                          Appropriate antibiotic utilization in ICU is crucial not only
is not commonly used in our setting. The sensitivity of                           in ensuring an optimal outcome, but also in preventing the
fosfomycin was better than imipenem and meropenem.                                emergence of multi drug resistance bacteria.
   Antibiotic use contributes to the emergence of
antimicrobial resistance in gram positive as well as gram
negative bacteria[2,12,13]. In developing countries, antibiotics                  Conflict of interest statement
are prescribed for 44%-97% of patients in hospital, often
inappropriately[14,15]. In Indonesia, a high proportion (84%)                        We declare that we have no conflict of interest.
of patients in hospital received an antibiotic but 32% of
prescription is an inappropriate indication[3].
    In Asian countries including Indonesia, the most                              Acknowledgements
frequent pathogen isolated from infections in the ICU
are P. aeruginosa, Klebsiella spp., E. coli, Enterococcus,                          We would like to acknowledge The Fatmawati Hospital
and Staphylococcus aureus. For example, in 12 ICUs in                             Jakarta, for research collaboration between Department of
seven Indian cities, overall 87.5% of all Staphylococcus                          Pharmacy, University of Indonesia and Fatmawati Hospital
aureus health care associated infections were caused by                           Jakarta, Indonesia.
methicillin-resistant strains, 71.4% of Enterobacteriaceae
were resistant to ceftriaxone and 26.1% to piperacillin-
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